An independent Police Conduct Authority report has today been released into the police response to events preceding the murder of Diane White in Frankton on Tuesday 19 January 2010. (http://www.ipca.govt.nz/)
Christine Judith Morris, a voluntary inpatient in Henry Rongomau Bennett Centre at the time, was later found guilty of the murder.
The authority investigated the police response after Mental Health and Addictions staff notified them by both fax and telephone that Ms Morris had “escaped” from Henry Rongomau Bennett Centre and had threatened to kill her next door neighbour, Diane White.
Our statement from Dr Rees Tapsell* today follows:
“We acknowledge the release of the Independent Police Conduct Authority report, the impact the report will have on Diane White’s family and we offer our sincere condolences to them.
“There are clearly things that Henry Rongomau Bennett Staff could have done differently in retrospect knowing now what we know about the defendant’s state of mind. We have spoken to the staff involved about some of those things but no one acted negligently or unprofessionally and no one person could reasonably be held responsible.
“We would like to clarify a couple of points in the report:
- The community support worker (as opposed to social worker as described by the police) was not employed by Waikato DHB but by a non Government organisation (NGO).
- Staff made a reasonable judgement to allow Ms Morris to have a cigarette in the courtyard to cool down. While in the courtyard, she scaled the fence and staff were unable to stop her. They then contacted the police as described in the authority’s report.
Below is our release made on 2 April 2012 following Christine Morris’ sentencing
* Dr Rees Tapsell is the Executive Clinical Director of PUAWAI: The Midland Regional Forensic Psychiatry Services and Director of Clinical Services, Waikato DHB Mental Health and Addictions.
Waikato DHB statement following murder sentencing
The defendant Christine Morris was a voluntary inpatient receiving respite care in the Henry Rongomau Bennett Centre in Hamilton, up until she went absent without leave two hours before killing Diane White in January 2010.
She has pleaded guilty to a charge of murder and was sentenced today.
Waikato DHB Mental Health and Addictions director of clinical services Dr Rees Tapsell expressed both his and the service’s condolences to the family and friends of Mrs White for their tragic loss.
The defendant was a long standing client of Mental Health and Addictions and was deemed to be a complex client, with high needs.
Waikato DHB undertook a Serious and Sentinel Events review of the circumstances that led to her leaving the ward. This review was conducted by a panel of very senior clinicians from outside Waikato DHB.
“I am not at liberty to discuss the details of this review as it was conducted as part of a protected quality assurance activity,” Dr Tapsell said.
He acknowledged that some people might find this unsatisfactory but asked that they understand that such protection is necessary so that staff are able to freely review important issues related to such incidents.
“This will assist to avoid such a tragedy in future and improve the quality of services provided to the people Waikato DHB cares for.”
Dr Tapsell acknowledged that the public would have a number of questions for Waikato DHB related to this tragedy and questions have been raised by the media.
Our responses are:
- Could this tragedy have been predicted, and therefore avoided?No one could reasonably have predicted this tragedy. The review did, however, identify a number of areas for service improvement. These included:
- Improved training in risk assessment and management
- Increased awareness of the policy on the observations of patients at risk
- Reviewing the open ward environment.
Each of these recommendations has been acted on.
- Is any one person to blame for this and, will anyone lose their jobs?No. Staff acted with the best of intentions. There are clearly things that the staff would have done differently in retrospect knowing now what we know about the defendant’s state of mind. We have spoken to the staff involved about some of those things but no one acted negligently or unprofessionally and no one person could reasonably be held responsible.
- Having realised that the service user had absconded from the ward did staff act promptly to inform the appropriate authorities? Did Waikato DHB staff contact the police? And when contacted by members of the public, is it correct that staff advised them to ring the police?
- Waikato DHB staff faxed a missing persons form to the police a few minutes after the defendant scaled the fence and left Henry Rongomau Bennett Centre
- Staff then rang the watch tower number at Hamilton Police Station provided by the police as part of Henry Rongomau Bennett Centre’s “missing from the ward procedure”
- There was no answer so staff rang an alternative number provided by the police. It was answered and police confirmed they had received the fax
- Staff asked to speak to a police officer about the threats, the call was transferred to another extension but there was no answer
- Staff rang 111 and said there was a patient absent without leave from the Henry Rongomau Bennett Centre and that the patient had threatened to kill a woman and gave the police the woman’s address.
- Staff made two more calls to the police with updated information
- Staff advised members of the public who rang into Henry Rongomau Bennett Centre to contact the police.
- Could this ever happen again?It is impossible to say with certainty that an incident like this would never happen again. Dr Tapsell is confident, however, that the combination of the implementation of the recommendations from the review and other service driven quality improvements will minimise the future likelihood of such a tragedy.
Dr Rees Tapsell is the Executive Clinical Director of PUAWAI: The Midland Regional Forensic Psychiatry Services and Director of Clinical Services, Waikato DHB Mental Health and Addictions.
Related release: Waikato DHB chief executive statement re Frankton murder
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